Download Intermediate Care Beds

Principles of Medical Cover
for
Intermediate Care Beds
This guidance follows a workshop held at Lagan Valley Island in October
2012 where stakeholders from Trusts, HSCB, NIGPC, RQIA, LCGs,
DHSSPS and PHA reached agreement on regional principles as to the
medical management of patients occupying HSC Trust owned
Intermediate Care Beds. It supersedes previous draft papers circulated.
The points discussed at this workshop are summarised in Appendix 1.
Background
Transforming Your Care describes an overall strategic goal of
maintaining people in the community, avoiding unnecessary hospital
admissions and ensuring timely discharge from the acute sector. This is
reflected in the HSCB Commissioning Plan for 2012/13. Intermediate
Care Beds are part of this. If Intermediate Care Beds did not exist these
patients would be in hospital.
The King’s Fund definition of Intermediate Care is as follows:
A short-term intervention to promote and preserve the independence of
people who might otherwise face unnecessarily prolonged hospital
stays, or inappropriate admission to hospital or residential care. The
care is person centred, focused on rehabilitation and delivered by a
combination of professional groups with either a therapeutic or specialist
medical lead where required.
Intermediate Care Beds are one way of delivering this short- term,
rehabilitation focused, service to appropriate patients. Governance
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concerns have highlighted an urgent need to clarify the definition of
these beds, who is medically responsible for the patients in them and
how the prescribing and dispensing needs of these patients are met in a
legal, safe and timely manner.
An Intermediate Care Bed is “a bed with a purpose” and the patients
admitted to them should have the potential to benefit from a package of
planned interventions. The principles outlined in this guidance flow from
this definition. Information obtained from the five trusts in Northern
Ireland would suggest that the term “intermediate care” has been
variously interpreted and there are few true Intermediate Care Beds
falling within the definition above.
Intermediate Care Beds are only a small subset of a variety of
arrangements currently providing post-acute and non-acute care. This
guidance does not address palliative care, respite care, longterm care,
community hospitals, rapid response nursing or a number of other
packages currently in place although consideration as to how these
principles might relate to those other settings may be useful at a later
date.
Aim
The aim of this guidance is to provide clarity as to who is medically
responsible for the patients in Intermediate Care Beds thus
providing a basis for commissioning of Intermediate Care Beds
using a consistent approach across all five trusts.
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Principles of Medical Cover for Intermediate Care Beds
General Principles
1.
The medical care provided in an Intermediate Care Bed is outside
General Medical Services (GMS).
2.
An Intermediate Care Bed is a short term treatment facility, not a
place of residence.
3.
Intermediate Care Beds should be concentrated in a small number
of appropriately resourced facilities.
4.
An up to date list of the locations of these Intermediate Care Beds
in each Trust area should be available to General Practitioners, relevant
Consultants, Commissioners and RQIA.
5.
Overall responsibility for the patients in Intermediate Care Beds
remains with the Trust.
6.
A patient admitted to an Intermediate Care Bed should have an
outcome focused management plan and the potential to improve enough
to return home (which includes residential accommodation) after a short
stay in the intermediate care facility.
7.
Spot purchase of isolated “intermediate care beds” in nursing
homes not already set up to deliver intermediate care should not occur.
8.
Where the patient’s need is solely for social or nursing care they
should be admitted to a normal nursing or residential home bed and not
an Intermediate Care Bed. Patients in normal nursing home and
residential home beds are entitled to GMS.
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Clinical Responsibility
9.
The Trust retains overall medical responsibility for a patient 24/7
until the patient is discharged back to normal GMS care. This includes
provision of adequate out of hours cover. Appropriate medical care
(routine and emergency) must be available to patients in Intermediate
Care Beds at all times.
10.
Medical responsibility will determine indemnity and governance,
including complaints and adverse incident management
11.
Either a Consultant or a General Practitioner on the NI Medical
Performers’ List must be ultimately medically responsible for each
patient at any given time.
12.
The Trust can decide whether they wish to provide consultant led
medical care and employ other doctors to provide first line treatment
under consultant direction or to subcontract the medical care to suitably
qualified and indemnified providers. This decision will be influenced by
the interventions planned and the admission criteria for each facility, for
example how medically stable a patient needs to be before admission.
13.
It is the Trust’s responsibility to ensure that staff employed, and
providers contracted with, are appropriately skilled, trained and
indemnified. It is for each individual doctor to assure themselves that
their skills and medical indemnity are appropriate for any work they
undertake.
14.
Nursing staff looking after patients in these Intermediate Care
Beds will require skills and training above a standard nursing home role.
This will be regulated by RQIA.
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15.
Consultants, General Practitioners, nursing home staff, patients
and their relatives must be clear who is responsible for the medical care
of a patient in any particular facility. This has important implications for
governance, indemnity and prescribing.
16.
To avoid confusion with the patient’s registered GP, the doctor
providing the first line medical care to patients in Intermediate Care Beds
should be referred to as a “Medical Officer”, even when they are also a
General Practitioner.
17.
Patient medical records for Intermediate Care should be distinct
from both secondary care and primary care notes. They should clearly
document the Intermediate Care stay and relate to the management
plan.
Admission to an Intermediate Care Bed
18.
Admission criteria for each facility should be agreed in advance by
the Trust. Patients should be medically appropriate for admission to
these Intermediate Care Beds as defined by agreed criteria.
19.
Patients should have an adequate assessment and a management
plan before admission to an Intermediate Care Bed.
20.
The management plan should be agreed between the medical
staff, therapists, nursing staff, the patient and their relatives and set out
what treatment and rehabilitation is planned. The plan should include the
estimated date of discharge, any anticipated discharge needs and
provision for reassessment by the acute sector should the patient’s
condition deteriorate. The “Medical Officer” should regularly review this
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plan while providing medical care during the patient’s stay in the
Intermediate Care Bed.
21.
When medical responsibility is transferred within the Trust from the
acute hospital care to an Intermediate Care Bed, an adapted hospital
discharge letter should accompany the patient. A sample based on
GAIN guidance is shown at Appendix 2. This should be copied to their
registered GP for information although their medical care is not being
transferred back to General Medical Services (GMS) at this point.
22.
Transfer from any acute unit should be planned in advance with
adequate regard to requirements for medicines, dressings and
appliances and equipment for delivery of necessary medicines e.g.
oxygen. Sufficient medication should accompany the patient to the
Intermediate Care facility.
Discharge from Intermediate Care Bed to General Medical Services.
23.
When medical responsibility is transferred from Intermediate Care
to GMS, a written (can be electronic) discharge letter (Appendix 2)
should immediately be sent to their registered GP and a copy should
accompany the patient. This also applies when discharge is to a normal
nursing home bed at the same location as the Intermediate Care Bed.
24.
Date of discharge should be regularly reviewed.
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Prescribing & Dispensing
25.
Prescribing responsibility follows from medical responsibility.
26.
Repeat medications or other General Medical Services should not
be requested for a patient from their registered GP as the patient’s
medical care has not been transferred back to their GP for GMS.
27.
Patients should have access to pharmaceutical service provision
to a level of that provided within an acute hospital setting. This should
include provision of clinical pharmacy services as appropriate, including
medicines reconciliation, medicines review and optimisation.
28.
Prescribing for patients in Intermediate Care Beds is outside GMS
24 hours per day and should not be written on a Standard GMS HS21
prescription pad. An alternative operational solution must be made
available.
29.
The HSC Trust will be responsible for prescribing and the safe and
efficient supply of all medications required by a patient throughout their
stay in an Intermediate Care Bed including the supply of discharge
medicines. This can be either from the Trust pharmacy or via a contract
with another provider. On discharge from an Intermediate Care Bed to
GMS the patient should be supplied with medication as per normal Trust
discharge medication policy.
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Access to specialist advice & diagnostics
30.
There must be timely access to laboratory and other diagnostic
tests as clinically appropriate in a treatment facility. The Intermediate
Care facility should be assured of an agreed turnaround time for any
investigation or intervention to allow them to manage the patient
effectively in the Intermediate Care setting. Should the patient’s
condition deteriorate swift access to clinical assessment by a doctor on
site should be available as appropriate.
31.
Referrals to specialist advice and services should be possible from
Intermediate Care Beds. Referrals should include contact details of the
patient’s registered GP. Details of the referral should be noted in the
discharge letter to the patient’s GP.
32.
Each Intermediate Care facility should have a unique identifier to
enable use of LabLinks, electronic referral systems and other systems
requiring a cipher.
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LCG Responsibilities
The LCG is responsible for:
 commissioning Intermediate Care Beds in line with these
principles,
 ensuring that these principles are incorporated into Trust delivery
plans for intermediate care and
 monitoring the service provided.
Trust Responsibilities
It is now for each trust to align their operational arrangements for
Intermediate Care Beds in parallel with these principles. For most, this
will involve as a minimum:
1. Consolidation of Intermediate Care Bed capacity to a smaller
number of beds at identified facilities.
2. Development of clinical governance protocols and procurement
arrangements detailing how they will secure:
o Appropriate medical cover for Intermediate Care Beds, either
consultant led or subcontracted to another provider.
o Prescribing and dispensing arrangements.
o Discharge protocols from acute beds to Intermediate Care Beds
and from Intermediate Care Beds to General Medical Services.
o Diagnostics and specialist advice for patients in Intermediate Care
Beds
o Clinical record keeping
Trusts are asked to nominate a single director to lead on Intermediate
Care within in their Trust. This director will ensure that the
recommendations detailed above are delivered and secure the required
co-ordination across the multiple organisations and professional groups
involved.
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Appendix 1
Outcomes of the Intermediate Care Beds Workshop, October 2012.
General Points
 Intermediate Care Beds must offer a focused package of care
which is significantly more intense than that available in ordinary
nursing home beds or in the community. The intended function of
these beds would determine how they are set up and may vary
between locations.
 Intermediate Care Beds can be part of re-ablement pathways.
Patients should only be in hospital if they need to be and
Intermediate Care Beds can provide appropriate management for
some patients in a lower cost setting than acute care. Intermediate
Care Beds will require additional investment. Accounting should be
done per pathway not per bed.
 There was a consensus that these beds should be concentrated in
small number of appropriately resourced facilities.
 An agreed set of principles should apply to all Intermediate Care
Beds and within this framework operational issues are for local
resolution.
 The level of medical support provided in Intermediate Care Beds
will be a matter for the Trust to decide depending on how they wish
to use them. This must be agreed in advance with any other
provider they intend to contract with.
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Admission to Intermediate Care Beds
 Before admission to an Intermediate Care Bed patients should
have had an acute assessment to ensure an appropriate working
diagnosis. This will inform the management plan which must focus
on what is the best option for the patient. From the outset the
management plan should be clear, structured and outcome
focused with appropriate timeframes. The management plan
should be updated regularly based on the patient’s condition and
should travel with the patient.
 In all cases communication with the patient and their General
Practitioner is vital. Figure 1 shows a clockwise progression from
home, to assessment & diagnosis, then treatment with a return
home as the ultimate goal.
 In some cases Intermediate Care Beds can avoid admission to
secondary care providing that there is access to appropriate
assessment and diagnostics to enable a management plan to be
developed prior to admission. From this perspective only step
down Intermediate Care Beds are envisaged although the “step
down” may be from an assessment unit or similar.
 Algorithms may help to clarify individual patient’s needs and
whether or not they are suitable for an Intermediate Care Bed. By
deciding the level of medical care and rehabilitation available in
particular intermediate care facilities this will determine the access
criteria and thus which patients are appropriate for admission.
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Figure 1: The Patient Journey (Clockwise only proposed)
Medical Assessment Unit
Consultant led
and/or
acute assessment
Emergency Department
& diagnostics
GP / GMS
Acute Care
HOME
Including Residential
ICB
Nursing
Home
Types of patient suitable for Intermediate Care Beds
 Patients who are medically stable but require medical care beyond
that provided by GMS or a rehabilitation package not available in
the community.
 Any patient who has the capacity to improve enough to return to
their previous residence should be considered for an Intermediate
Care Bed. These patients will require varying levels of medical
support.
o If sub acute but complex medical care is required this
probably should be Consultant led e.g. patient although
stable needs frequent review of medical management,
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clinical examination, altering prescribing, blood tests and
other diagnostics.
o If the patient is medically stable but is not yet well enough to
be at their usual address (or other suitable residence in the
community) and requires intense rehabilitation not available
at their usual address then it may be appropriate to sub
contract medical care to a group of General Practitioners.
 Improvement in the patient’s condition is expected; a patient
should be in an Intermediate Care Bed for defined clinical reasons
e.g.
o Patient with cognitive impairment and an acute illness
o Frail patients with a frail carer recovering from acute illness
o Post fracture rehabilitation
o Post stroke rehabilitation
Types of patient not suitable for Intermediate Care Beds
 Purely social admissions or only nursing care required.
 Crisis intervention
 Respite
 Waiting for long term care or another establishment
 Because no other option available
 Patients who can access same service in the community without
any risk of harm
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Regulation of Intermediate Care Beds
 Experience has shown that Intermediate Care Beds work well
when there is a dedicated intermediate care service within a
particular facility. This is reflected in the culture, philosophy, staff
attitudes and training at the facility which has implications for costs
and implementation of these beds.
 These beds should be managed as a service: DHSSPS describes
a minimum standard for intermediate care. RQIA would inspect
the facility with regard to the categories of care it is registered to
provide care within.
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